The Ethical Physician as Negative Gatekeeper?

Barnard David . “The Physician as Priest, Revisited.” Journal of Religion and Health 24 (Winter 1985): 272–286.

Brock Dan W. “The Ideal of Shared Decision Making Between Physicians and Patients.” The Kennedy Institute of Ethics Journal 1 (March 1991): 28–47.

Dougherty Charles J. “Ethical Values at Stake in Health Care Reform.” JAMA 268 (4 November 1992): 2409–2412.

Drane James F. Becoming a Good Doctor Kansas City: Sheed & Ward, 1988.

Emanuel Ezekiel J. , and Brett Allan S. “Managed Competition and the Patient-Physician Relationship.” The New England Journal of Medicine 329 (16 September 1993): 879–882.

Franks Peter , Clancy Carolyn M. , and Nutting Paul A. “Gatekeeping Revisited: Protecting Patients from Overtreatment.” The New England Journal of Medicine 329 (16 September 1993): 879–882.

Hillman Alan L. , Pauly Mark V. , and Kerstein Joseph J. “How Do Financial Incentives Affect Physician's Clinical Decisions and the Financial Performance of Health Maintenance Organizations?” The New England Journal of Medicine 321 (13 July 189): 86–92.

Keane Philip S. Health Care Reform: A Catholic View. Mahwah, New Jersey: Paulist Press, 1993.

Levinson Douglas F. “Toward Full Disclosure of Referral Restrictions and Financial Incentives by Prepaid Health Plans.” The New England Journal of Medicine 317 (31 December 1987): 1729–1731.

Macklin Ruth . Enemies of Patients. New York: Oxford University Press, 1993.

May William F. The Physician's Covenant: Images of the Healer in Medical Ethics. Philadelphia: The Westminister Press, 1983.

McDowell Banks . Ethical Conduct and the Professional's Dilemma: Choosing Between Service and Success. New York: Quorum Books, 1991.

Meserve Harry C. “Examining Doctors.” The Journal of Religion and Health 32 (Summer 1993): 85–90.

Morreim E. Haavi . Balancing Act: The New Medical Ethics of Medicine's New Economics. Dordrecht, The Netherlands: Kluwer Academic Publishers, 1991.

Morreim E. Haavi . “Fiscal Scarcity and the Inevitability of Bedside Budget Balancing.” Archives of Internal Medicine 149 (May 1989): 1012–1015.

Morris Tim . “Cost Containment and the Ethical Foundation of the Professional-Client Relationship.” Professional Ethics 2 (Spring/SUmmer 1993): 88–111.

Pellegrino Edmund D. , and Thomasma David C. The Virtues in Medical Practice. New York: Oxford University Press, 1993.

Pellegrino Edmund D. and Thomasma David C. , For the Patient's Good: The Restoration of Beneficence in Health Care. New York: Oxford University Press, 1988.

Pellegrino Edmund D. , Veatch Robert M. , and Langan John P. , eds. Ethics, Trust and the Professions: Philosophical and Cultural Aspects. Washington, D.C.: Georgetown University Press, 1991.

Reagan Michael D. “Physicians as Gatekeepers: A Complex Challenge.” The New England Journal of Medicine 317 (31 December 1987): 1731–1734.

Relman Arnold . “Practicing Medicine in the New Business Climate.” The New England Journal of Medicine 316 (30 April April 1987): 1150–1151.

Relman Arnold S. “Dealing with Conflicts of Interest.” The New England Journal of Medicine 313 (19 September 1985): 749–751.

Rodwin Marc A. Medicine, Money and Morals: Physician's Conflicts of Interest. New York: Oxford University Press, 1993.

Sevensky Robert L. “The Religious Physician.” Journal of Religion and Health 21 (Fall 1982): 254–263.

Shaffer Thomas L. Faith and the Professions. Provo, Utah: Brigham Young University Press, 1987.

The Lancet. “Calling All Gatekeepers: This is an Emergency.” The Lancet 343 (5 February 1994): 305–306.

Toon Peter D. “Justice for Gatekeepers.” The Lancet 343 (5 March 1994): 585–587.

Wear Stephen . “The Irreducibly Clinical Character of Bioethics.” The Journal of Medicine and Philosophy 16 (1991): 53–70.

Winslow Ron . “HMO Juggernaut” The Wall Street Journal 6 September 1994.

Wolf Susan M. “Health Care Reform and the Future of Physician Ethics.” Hastings Center Report 24 (March/April 1994): 28–41.

Parmet Wendy E. The Impact of Health Insurance Reform on the Law Governing the Physician Patient Relationship, JAMA 268 (1992): 3468–3472

Pellegrino Edmund D. , and Thomasma David C. , For the Patient's Good: The Restoration of Beneficence in Health Care, (New York: Oxford University Press, 1988): 189. Physician income accounts for 17-20% of the expenditures, but physicians control directly or indirectly up to 80% of all health care expenditures.

May William F. The Physician's Covenant (Philadelphia: The Westminister Press, 1983), 25-27.

See for example, Drane James F. , Becoming a Good Doctor (Kansas City: Sheed & Ward, 1988). Drane argues that the physician has become the modem priest. See also, Harry C. Meserve, “Examining Doctors,” Journal of Religion and Health 32 (Summer 1993): 85-90. Meserve argues for a strong spiritual component in the role of the modern physician.

Sevensky Robert L. , “The Religious Physician,” Journal of Religion and Health 21 (Fall 1982): 254–263. Sevensky uses the four concepts of vocation, neighbor, love and covenant to analyze the physician's role.

Barnard David , “The Physician as Priest, Revisited,” Journal of Religion and Health 24 (Winter 1985): 272–286.

Shaffer, 113-115. Shaffer makes a strong case for the relevance of character and story in determining the ethical code of the legal and medical professions.

May, 36–144.

May, 142–143.

Zaner Richard M. , The Fiduciary Relationship and the Nature of Professions,” in Ethics, Trust and the Professions: Philosophical and Cultural Aspects, eds. Pellegrino Edmund D. , Veatch Robert M. , Langan John P. (Washington, D.C.: Georgetown University Press), 47.

For a discussion of autonomy as it affects the physician-patient relationship see, Brock Dan W. , The Ideal of Shared Decision Making Between Physicians and Patients,” Kennedy Institute of Ethics Journal 1 (March 1991): 28–47. See also Stephen Wear, The Irreducibly Clinical Character of Bioethics,” The Journal of Medicine and Philosophy 16 (1991): 53-70. Wear argues persuasively for realistic expectations of patient autonomy based on policies drawn up by those with clinical experience in bioethics and medicine.

Pellegrino Edmund D. , and Thomasma David C. , The Virtues in Medical Practice (New York: Oxford University Press, 1993), 169–170.

See Waymack Mark H. , “Health Care as a Business: The Ethic of Hippocrates Versus the Ethic of Managed Care,” Business and Professional Ethics Journal 9 (no. 3 & 4): 68–78. Waymack argues that since a member enrolls voluntarily in an HMO and knows the “rules” of allocation, there is no conflict of interest on the physician's part when the patient is denied a possibly beneficial procedure or treatment due to cost constraints. There are several major problems with the argument in this paper. First, can the patient can absolve the physician of moral responsibility by a “freely” chosen contractual agreement? Further, since employees are free to choose only those plans offered by their employer, their freedom of choice may be illusory. Finally, an individual in our society is not “free” to sell him or herself into slavery. This paper maximizes the autonomous individual, but has absolutely no regard for the weak or powerless. It is a prime example of the emphasis on autonomy without sufficient concern for covenantal or fiduciary responsibilities.

Morris Tim , “Cost Containment and the Ethical Foundations of the Professional-Client Relationship: The Case of Physicians,” Professional Ethics 2 (Spring/Summer, 1993): 88–111. See also E. Haavi Morreim, Balancing Act The New Medical Ethics of Medicine's New Economics, Dordrecht, The Netherlands: Kluwer Academic Publishers, 1991), 93.

Pellegrino Edmund D. , and Thomasma David C. , The Virtues in Medical Practice (New York: Oxford University Press, 1993), 57–59.

Pellegrino Edmund D. , and Thomasma David C. , The Virtues in Medical Practice (New York: Oxford University Press, 1993), 53

See also Dougherty Charles J. , “Ethical Values in Health Care Reform,” JAMA 268 (4 November 1992) 2409–2411. Dougherty proposes three intrinsic values (respect for the dignity of persons, caring in therapeutic relationships and protection of the least well-off) and three instrumental values (service to the common good, containment of health care costs, and simplicity in the system of health care provision) as worthy of protection in a revised helath care delivery system.

Pellegrino , and Thomasma (1988), 40-61, 193–195

Pellegrino , and Thomasma (1993), 193–195.

Morreim E. Haavi , “Fiscal Scarcity and the Inevitability of Bedside Budget Balancing,” Archives of Internal Medicine 149 (May 1989): 1012–1015. (emphasis mine)

Pellegrino , and Thomasma (1988), 172–183.

Franks Peter , Clancy Carolyn , and Nutting Paul A. , “Gatekeeping Revisited: Protecting Patients from Overtreatment,” The New England Journal of Medicine (6 August 1992): 424–429.

Relman Arnold S. , “Dealing with Conflicts of Interest,” The New England Journal of Medicine 313 (19 September 1985): 749–751. Relman deals with these specific issues in this editorial.

Emanuel Ezekiel J. , and Brett Allan S. , “Managed Competition and the Patient-Physician Relationship,” The New England Journal of Medicine 329 (16 September 1993): 881.

The Lancet (editorial), “Calling all Gatekeepers: This is an Emergency,” The Lancet 343 (5 February 1994): 305–306

Rodwin Marc A. , Medicine, Money and Morals: Physicians' Conflicts of Interest (New York: Oxford University Press, 1993), 157–158.

Angell Marcia , “The Doctor as Double Agent,” Kennedy Journal of Ethics 3 (September 1993): 279–286.

Angell Marcia , “The Doctor as Double Agent,” Kennedy Journal of Ethics 3 (September 1993), 283–285.

Relman NEJM 313: 750.

Winslow Ron , “HMO Juggernaut U.S. Healthcare Cuts Costs, Grows Rapidly and Irks Some Doctors,” The Wall Street Journal, 6 September 1994

Rodwin 168.

Levinson Douglas F. , “Sounding Board: Toward Full Disclosure of Referral Restrictions and Financial Incentives by Prepaid Health Plans,” The New England Journal of Medicine 317 (31 December 1987): 1729–1730.

See Morreim E. Haavi , Balancing Act: The New Medical Ethics of Medicine's New Economics, Dordrecht, The Netherlands: Kluwer Academic Publishers, 1991), 81–100 for an excellent discussion on economic problems of distributive justice in the Health Care system.

Toon Peter D. , “Justice for Gatekeepers,” The Lancet 343 (5 March 1994): 585–587.

Cf. 20. In this article, the president and founder of US Healthcare's annual salary of S9.8 million dollars and $11.4 million in dividends on stock options is defended as “definitely not excessive” by the company's chief legal officer. One might question the wisdom of involving people with this mentality in discussions about health care reform. The salaries and compensation schedules of health care company officials should be open to scrutiny as much as physician fees and income.

Relman Arnold S. , “Practicing Medicine in the New Business Climate,” The New England Journal of Medicine 316 (30 April 1987): 1150–1151. Relman makes several practical suggestions for the physician to avoid conflict of interest: physician income should be limited to money earned by services personally provided or supervised; physicians should avoid any arrangements with a for-profit corporation that rewards them for choosing a particular service or facility; physicians should avoid direct employment by a for-profit corporation; physicians should not enter into an arrangement with any organization that directly rewards them for withholding services from their patients.

Hillman Alan L. , Pauly Mark V. , and Kerstein Joseph J. , “How Do Financial Incentives Affect Physicinas' Clincial Decisions and the Financial Performance of Health Maintenance Organizations?” The New England Journal of Medicine 321 (13 July 1989): 86

Wolf Susan M. , “Health Care Reform and the Future of Physician Ethics,” Hastings Center Report 24 (March-April 1994): 28–41. See also Michale D. Reagan, “Physicians as Gatekeepers: A Complex Challenge,” The New England Journal of Medicine317 (31 December 1987): 1731-1734.

Pellegrino and Thomasma, 94-116. See also Keane Philip S. , Health Care Reform: A Catholic View (New York, New York/Mahwah, New Jersey: Paulist Press, 1993), 136–144 for a discussion of the Catholic view of distributive justice in health care.